During a sterile dressing change, the nurse notices that the sterile field has been contaminated. What is the most appropriate action for the nurse to take?

Continue the procedure as planned.

Inform the patient about the contamination and continue.

Apply an additional sterile covering over the contaminated area.

Re-establish a new sterile field and restart the procedure.

Answer and Explanation

The Correct Answer is D

Choice A reason: Continuing the procedure with a contaminated field poses a significant risk to the patient by introducing potential pathogens into a wound site. This violates the fundamental principles of asepsis and increases the risk of healthcare-associated infections, which is clinically unacceptable nursing practice.

Choice B reason: Informing the patient does nothing to mitigate the risk of infection. While transparency with the patient is important, the clinical priority is to maintain a sterile environment. Continuing the procedure despite knowing the field is compromised is a direct breach of sterile technique and patient safety standards.

Choice C reason: Simply covering the contaminated area does not render the underlying items sterile. Once a sterile field is compromised, the integrity of the entire setup is lost. The only way to guarantee a sterile environment for the patient is to discard the compromised items and begin the process entirely from the start.

Choice D reason: Maintaining sterility is paramount to preventing post-operative wound infections. When a breach in the sterile field occurs, the nurse must assume that the field is no longer sterile. The standard of care is to immediately stop, discard the contaminated materials, and replace them with new, sterile supplies to ensure patient safety.

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Correct Answer is C

Explanation

Choice A reason: Frequent self-induced vomiting causes the loss of gastric acid, which is rich in electrolytes, particularly potassium and hydrogen ions. This typically leads to hypokalemia, not hyperkalemia. Hyperkalemia would be a dangerous electrolyte imbalance that is clinically inconsistent with the purging behaviors of bulimia nervosa.

Choice B reason: While amenorrhea is a common and hallmark feature of anorexia nervosa due to severe caloric restriction and low body mass index, it is not a diagnostic criterion or a consistently expected finding for bulimia nervosa. Clients with bulimia often maintain a weight within a normal range, which usually allows for the continuation of the menstrual cycle.

Choice C reason: Gastric acid from repeated self-induced vomiting passes through the oral cavity, which leads to the erosion of tooth enamel, known as perimylolysis. This process leaves the teeth susceptible to cavities, sensitivity, and severe dental decay, making it a highly expected clinical finding in patients with chronic bulimia nervosa.

Choice D reason: A defining clinical characteristic of bulimia nervosa is that the client’s body weight often remains within or above the normal reference range. This distinguishes it from anorexia nervosa, where significantly low body weight is a required diagnostic criterion. Weight fluctuations may occur, but low body weight is not an expected finding.

A. It is a gene variant that determines an individual's likelihood of recovering from mental illness. B. It is a gene variant that is responsible for an individual's resilience to stress. C. It is a gene variant that increases the risk for development of a specific mental illness. D. It is a gene variant that is responsible for the development of a specific mental illness.

Correct Answer is C

Explanation

Choice A reason: Recovery trajectories are complex and influenced by multifaceted biopsychosocial factors, including environment, support systems, and treatment efficacy. No single vulnerability gene is definitively classified as the primary determinant for the success of recovery, as this process remains multifactorial and highly individualized across clinical populations.

Choice B reason: Resilience to stress involves complex neurobiological and psychological adaptations, often linked to gene-environment interactions. A vulnerability gene, by definition, implies a predisposition to pathology rather than the inherent biological mechanisms that promote the capacity to cope, adapt, or thrive under adverse life circumstances.

Choice C reason: A vulnerability gene (or susceptibility gene) increases the statistical probability that an individual will develop a specific disorder when exposed to certain environmental triggers. It does not guarantee the disease, but it lowers the threshold for pathogenesis by affecting neurodevelopmental pathways or neurotransmitter regulation systems.

Choice D reason: Few, if any, mental illnesses are caused by a single gene. Most psychiatric conditions are polygenic and multifactorial. Attributing the absolute development of a mental illness to one gene is scientifically inaccurate because the expression of these conditions almost always requires the interaction of genetic predisposition and environmental factors.

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During a sterile dressing change, the nurse notices that the sterile field has been contaminated. What is the most appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client who has bulimia nervosa and reports frequent self-induced vomiting. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse in an outpatient facility is reinforcing teaching to a client about the development of mental illness. Which of the following statements by the nurse describes the role of a vulnerability gene?

Correct Answer is C

Explanation

A nurse is providing information to a client about risk factors for developing an anxiety-related disorder. Which of the following clients is at greatest risk for developing an anxiety-related disorder?

A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?

A nurse is caring for a client who has bulimia nervosa has a new prescription for a selective serotonin reuptake inhibitor (SSRI). Which of the following medications should the nurse anticipate administering?

Which complication is a nurse most likely to suspect if a patient develops erythema and warmth around a wound after a sterile dressing change?

A nurse is assisting with the care of an adolescent who has an anxiety disorder. Which of the following statements by the adolescent indicates a protective factor in the form of a positive childhood experience?

What step should a nurse prioritize when preparing for a sterile dressing change to minimize infection risk?

A nurse is collecting data on a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

A nurse is assisting in the care of a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identify that these manifestations indicate which of the following?